Controversial new procedure to alleviate pain

Kim Kyle Morgan

Published 4:53 pm, Tuesday, December 10, 2013

Imagine having a headache for three years. That's what happened to Brittany Lawrence of Rosharon, Texas, now 21, when she was in

junior high school.

"I woke up with a headache, but I have never felt pain like that before," Lawrence said. "My mom thought it was a migraine."

A trip to the emergency room alleviated the pain, but it never went completely away. This triggered numerous trips to doctors, including four neurologists and the occasional hospitalization. Lawrence had to stop going to school because the bright, fluorescent lights and bells that signaled classes' beginning and end were agonizing.

"I didn't think I was going to ever have a life again," Lawrence said. "I thought I was doomed to living in a bed in the back of my parents' house."

Eventually, Lawrence learned her headaches were nerve related, but she still couldn't find relief.

"In some people, the nerve becomes flattened out and compressed within the muscles, leading to an inflammatory response," Blake said. "This irritation causes pain in the back of the head that may radiate to the forehead or temples. It can hurt just to lay your head on a pillow at night." Nerve-block injections provide temporary relief, she said, but a more permanent solution is nerve decompression surgery, which is what Lawrence underwent when she was 15.

"I had relief that day," said Lawrence. "I woke up from the surgery and had no pain." Blake said not very many places perform nerve decompression surgery as a treatment for headaches, but Houston does. Lawrence works with Memorial Hermann surgeons Dr. Carlton Perry, Dr. Jason Hall and Dr. Azul Jaffer. "Is it a cure? I think it could be," Blake said. "I think it's going to dramatically change how we treat people with chronic daily headaches in the future. It's a new way of thinking about headaches."

In Connecticut, those who have performed the surgery include Dr. Alain de Lotbinière, an attending neurosurgeon at Greenwich Hospital. He said he does the surgery rarely, and only when a block of occipital nerve is shown to relieve pain. "The mistake would be to do surgery for every single headache," he said. There are still some reservations about the procedure, de Lotbinière said, as, to his knowledge, there haven't been any trials documenting its effectiveness.

That lack of research gives many pause, including said Dr. Peter McAllister, director of the Headache Center at Associated Neurologists of Southern Connecticut. McAllister, who is affiliated with St. Vincent's Medical Center in Bridgeport, said nerve decompression surgery is a hot topic of discussion among those with chronic headaches, but he's leery about it because of the lack of research around it. "Although there's been hype about it and there's hope and strong feelings, the data behind it is terrible," McAllister said.

He pointed out that the American Headache Society, a professional society of health care providers dedicated to the study and treatment of headaches, has urged caution in using surgery to treat headaches, specifically migraines. The society has posted a statement to that effect on its website.

"Unfortunately, there is no cure for migraine," it reads. "Many therapies, including medications, alternative therapies and surgical interventions, are aimed at reducing migraine frequency or stopping the pain and associated symptoms after they've begun, but none are `cures.' "

But there are those who say the procedure gave them relief that had previously evaded them.

Affecting about 46 percent of people worldwide, headaches rank among the top 10 most disabling conditions, according to the World Health Organization. Maureen Lall, a nurse practitioner at the recently opened Headache Center at Houston Methodist Sugar Land Hospital, said tension headaches are the most common, affecting 42 percent of people. Migraines affect 11 percent, and chronic daily headaches affect 3 percent.

She said women are three times more likely to experience migraines than men, and the highest rate is among women between the ages of 18 and 44.

"It can be so disabling for these women," Lall said. "That's the time of maximal family obligations. To not be able to function at that time of life is incredibly difficult." Migraines tend to become less severe and less frequent with age, although that wasn't the case for Patricia Haake.

Now 80 years old, the Houstonian said her earliest memory of a debilitating headache was when she was 9.

"It's a feeling like my skull shrank and my brain grew -- a lot of pressure in there," said Haake, who was in her early 30s when doctors officially diagnosed her migraines.

Her latest attack was in October 2012, a migraine that lasted an entire month, she said, until she received 10 Botox shots at the Headache Center at Houston Methodist Sugar Land Hospital.

"Since then, I've been able to stop the migraines before they come," said Haake, referring to the use of prescription medication that prevents full-blown migraine attacks if taken in time.

Migraines run in Haake's family, dating back as far as her great-grandmother. "It's a hereditary thing," she said.

Family history is a significant component when diagnosing migraines. That's why it's important to create and maintain a headache history.

Lall said the journal should be detailed, with information such as what time you went to bed, what time you woke up, what you ate, whether you were emotionally stressed and if you had caffeine or alcohol.

All headaches can be triggered by myriad factors, including diet, hormones, stress and illness. And different types of headache manifest in different ways.

Tension headaches feel dull and achy, Lall said, and are often accompanied by a sore neck. Migraine headaches are characterized by throbbing, severe pain that lasts anywhere from four to 72 hours. Chronic headaches are those occuring more than 14 days in a month, and the pain is moderate to severe. Cluster headaches are a rare condition characterized by sharp, severe pain on one side of the head and lasting about 45 to 90 minutes.

"There's a system of connections between the nerves that come in and out of the head, the brain itself -- especially the cortex and the meninges -- and blood vessels," DiTommaso said. "Symptoms depend on which of those areas is more irritated." Headaches that have you reaching for pain medication more than twice a week should be evaluated by a physician. Rebound headaches are caused by overuse of medication, resulting in a vicious cycle of pain, meds and more pain.

While it may be hard to think beyond the immediate pain of a headache, there are long-term implications as well.

Lall said headache is one of the most costly illnesses in industrialized countries. "Direct costs, which include all health-care costs caused by a disease, such as medications, office visits, emergency department visits and laboratory and diagnostic services, exceed $20 billion annually in the U.S., Lall said. "Headache is also associated with high indirect costs due to absenteeism and reduced productivity."